DRAFT note of meeting

Transcription

1 Neurosurgery Managed Service Network Operational Management Group 20 September 2010, 10 a.m. Conference Room A, St Andrew s House, Edinburgh DRAFT note of meeting Present: Apologies: Mr Eric Ballantyne, Chairman Mrs Carolyn Annand, senior neuroscience nurse, NHS Grampian Mrs Linda Beecroft, MSN audit facilitator, NHS Greater Glasgow & Clyde (observing) Miss Jennifer Brown, lead neurosurgeon, NHS Greater Glasgow & Clyde Ms Diane Fraser, speech & language therapist, NHS Lothian Mr Emmanuel (Manny) Labram, lead neurosurgeon, NHS Grampian Mr Peter Meager, development manager, Dystonia Scotland Ms Susan Walker, general manager, NHS Greater Glasgow & Clyde Miss Fiona Maxwell, MSN manager Mr Colin Briggs, head of service, NHS Lothian Mr Mike Fitzpatrick, lead neurosurgeon, NHS Lothian Mr Douglas Gentleman, MSN data and audit group Ms Ruth Hymers, dietitian, NHS Lothian Mr Derek Louttit, Scottish Ambulance Service Miss Lynn Myles, MSN standards development group Ms Lynn Smith, service manager, NHS Tayside 1. Welcome, introductions, apologies Eric opened the meeting noting apologies as above. May Vobes, service manager from NHS Grampian, had retired and her replacement was not yet in post. He welcomed Linda who had recently started in her post as audit facilitator for the Glasgow service. 2. Note of last meeting There were no comments on the note of the 4 June meeting, which was accepted as an accurate record of the discussion. 3. Matters arising All matters arising would be covered in the agenda. 4. Provision of DBS in Scotland Eric noted that this item was scheduled to be discussed at the last meeting but there had not been time. He invited Peter to speak to his summary of DBS provision in Scotland. Peter explained that DBS was mainly used for movement disorders in Parkinson s disease and dystonia, and in a few rare cases could be used for severe depression. In simple terms, the procedure involved the placement of 2 electrodes in the brain which were connected to a pulse generator emitting pulses at a specific frequency, which effectively cancelled out abnormal brain activity. Available data suggested a steady rise in activity, with average numbers per year rising from 5 to 10 in the last 10 years. The most up to date figures for 1

2 activity in indicated a further rise of up to 25 new implants. Of these, 68% were for Parkinson s disease. Peter had been in contact with patients and neurologists in preparing the summary. Only three of the four neurosurgery units offered the procedure with a interesting view from an Aberdeen neurologist that none of the Scottish centres were doing enough cases to maintain expertise, particularly in patients who required complex follow-up. His preference would be for an established centre in Scotland, but meantime he tended to send patients to London. Those patients who were seen in London had to go back for follow up, since the Scottish centres seemed unable to receive information from London to allow follow up closer to home. The general issue was that there was no agreed protocol, and that the service was actually not available on equitable terms for patients being referred for assessment. Peter felt there was also a need to look at the volume/maintenance of skills issue, since ideally all neurologists should have confidence in whatever teams were carrying out the procedure in Scotland, which should make referral to England unnecessary for any other than the most complex cases. Peter reported that Paul Eunson (consultant paediatric neurologist, NHS Lothian) had proposed the establishment of a children s service in Edinburgh, but it was not clear what stage that proposal had reached. Peter added that that it was not clear whether activity had now reached a peak or would continue. He noted, however, that while the treatment was previously only recommended for generalised dystonia, DBS was now being considered where cervical dystonia was not reactive to botulinum toxin. Eric asked whether the increase in activity was specific to any one centre. Peter replied that the summary was based on activity information from Medtronic. It appeared that the majority of the increase in activity had been in Edinburgh, though it was difficult to achieve an exact figure without information from individual centres. Eric noted that there were several companies now involved in implant supplies. Jennifer commented on this situation as an example of centres developing independently of each other, therefore none had thrived and established an all-scotland service. She thought there shouldn t be any need for patients to go to England for treatment. However, she commented that perhaps all centres were not appropriately resourced and organised to provide good, coordinated follow up. In Glasgow, neurophysiology provision was much improved, but had been supported by Alan Forster coming from Aberdeen. She thought the MSN should help to coordinate the provision of this service in future. Eric commented that patients were being referred in an unstructured way. He agreed with Jennifer s analysis of the situation. He felt that it would be entirely appropriate for the MSN to take this forward with the aim of providing a more coordinated service. He asked whether issues with the provision of service were mainly to do with neurosurgical competence or whether neurologists were also feeling that they did not have enough experience to deal with this patient group effectively. Manny suggested that issues were both surgical and medical, and that if there were agreed protocols and pathways, everyone would be happy to follow these. 2

3 Eric commented that with a predicted increase in activity and a number of suppliers looking to secure new clients, purchasing as a single service could be cost effective. Susan agreed that the MSN should take advantage of a national procurement process. Jennifer noted that functional neurosurgery was a popular subspecialty, and asked whether there was an unmet need or whether Scotland was overproducing surgeons who wanted to do this type of work. While surgical competence was relatively easy to achieve, some more robust idea of actual need would be helpful in planning. Eric commented that the follow up for some of these patients is high maintenance, with adjustment to equipment and changes to disease. Jennifer agreed there would be a considerable role for neurologists and specialist nurses as well as surgeons, but unmet need would have to be quantified. Susan asked whether the reasons behind current referral patterns were known. Eric replied that they were largely historical. Mr Varma in Dundee had taken a large number of referrals, work that Professor Eljamel had continued. Meantime Glasgow and Edinburgh had started providing for this patient group as well, but anomalies still existed, e.g., Ayrshire referred patients to Dundee. This had not been rationalised. Eric proposed that the OMG should recommend some further work to the Board on this, to look at referral patterns, size of service, activity and outcomes, defining what sort of follow up there should be, and whether there was any issue about competence. Action: EB 5. Spinal surgery workload Eric reported that a joint orthopaedic/neurosurgery meeting was scheduled for the last week in September, so there was not much progress to report before that meeting had taken place. The aim of the work was to agree which patients should come into the surgical stream and where and how should they be managed. There would have to be decisions on whether orthopaedics wished to continue to provide any spinal service. Jennifer agreed that the choice would have to be either for orthopaedics to take some of the caseload, or for the entire caseload to be treated in neurosurgery with resource transferring along with the additional work. Either way, she felt, it was not a good model to have a single orthopaedic surgeon doing occasional operating on spinal cases. Susan commented that even if resource could be transferred, volume in neurosurgery had increased generally, so there was actually no resource to transfer. Jennifer acknowledged this and added that there were also other constraints on activity, such as theatre and outpatients. Eric commented that the 18 week RTT target seemed quite arbitrary and did not take account of the clinical condition, or the result of a wait and see approach to treating this particular condition. Jennifer stressed that each service needed the flexibility to make priority decisions unaffected by the requirement to treat these cases within such timescales. Susan suggested that a robust clinical discussion and argument supporting a change in how these patients was managed was necessary. Jennifer agreed, pointing out that if the 3

4 neurosurgery/orthopaedic group could come up with clinically sensible targets for this patient group, there may still be capacity issues in meeting them. 6. Updates 6.1 Paediatric and adult epilepsy services Eric reported that the MSN Board had approved the OMG s proposals for running the adult service. The epilepsy group had met in Glasgow a few weeks previously and a second meeting was to be scheduled for January. There should be an audit facilitator in place by then to provide administrative and MDM coordination support to this meeting. Paediatric epilepsy surgery, and the proposal to establish a national service, had taken a different route. The MSN had been supportive but less involved in the bid, which had gone to NSAG via NSD in the usual manner. It had, however, been rejected on financial grounds. Work was in progress on trying to find out true costs of the service currently provided from Great Ormond Street, which seemed unrealistically low, and trying to trim the costs of the proposal from Edinburgh to see if it could be made more comparable in terms of costs. Jennifer noted that any further bid should consider in more detail more what resource was place already. Susan also commented that other Boards should be consulted, e.g., Greater Glasgow and Clyde women s and children s services. Eric noted these points and assured the group that if the bid was to be resubmitted it would come back to the OMG/MSN Board. 6.2 Paediatric advisory group/nscg Eric reported that he had been looking at what facilities were available where; in light of the guidelines on transfer form BPNG/RCoA. Main concerns seemed to be around transport and anaesthetics. He was still to finish this work and would report back in due course. Work was also continuing with the Safe and Sustainable paediatric neurosurgery work in England. Mr James Steers had reviewed the 15 units that were bidding for designation as paediatric services within the standards that had been set. The result was that none of the 15 units could achieve the standards completely. What had emerged, from discussions with families, was that the model that worked best was one that involved adult/paediatric co-location and multidisciplinary working. It seemed that it was quite clear to parents where communication was failing. It had been suggested that rather than stand alone children s hospitals, which suffered from an absence of interaction with adult services making transition quite difficult, a service with mixed practice worked better. The ideal model might be one run by neurosurgeons with paediatric experience but mixed practice, where children could be looked after in a paediatric setting in an adult hospital. A final report was being drafted and should be available in December. Susan asked about the paediatric anaesthetists view of these discussions. Eric replied that there had been good anaesthetic representation at the last meeting. He felt the view had been that anaesthetic skills should not be so concentrated in paediatric neurosurgery, and that a general view in favour of centralisation was moderating. 4

5 Eric reported that the group had also produced some activity figures, which were not particularly clear in the way they had been reported, with a large number of procedures falling onto an other procedures category. The next meeting was in December. 6.3 Standards development group 6.4 Data and audit Neither Douglas nor Lynn was able to attend; Fiona gave a brief update. The final version of the standards document would be distributed in October, since a final phase of consultation had been completed. The group was hopeful of a statement of endorsement from the SBNS. Audit facilitators had been appointed in both Aberdeen and Glasgow, with the Dundee post to be advertised shortly. Work was progressing on the development of the MiDIS system. 7. Staffing/appointments Eric gave an update. Mr Barlow (Glasgow) was due to retire at the end of November, although Susan noted that with leave to take he would probably be finishing work about a month before then. Shortlisting for his replacement was taking place. There had been 16 applicants, and Eric and Jennifer agreed that there was a very strong field of candidates to chose from. Susan reported that the funding for the new post was not yet approved. Eric noted that Mr Russell (Edinburgh) was also due to retire, and as far as he knew there was still no decision on whether that the post would be replaced. EB confirmed that as a group, the OMG was expected only to comment on the suitability of any proposed replacement post, not on whether any individual unit required additional posts to cope with activity. It was up to individual Boards to decide what they felt they could fund within their own resources. Manny commented that in Aberdeen, problems were mainly at middle grade. While training numbers were set nationally and therefore difficult to change, the unit was having difficulty in identifying funding to develop a middle grade post. Currently the unit had only one SpR post, two FY1 and two FY2 any additional cover was provided by neurology. The service was, however, EWTR compliant on paper with all posts filled. Eric noted that for four consultants there should be 2 trainees. Manny agreed, but there was only one which was why they were interested in developing a middle grade post. Eric reported that in Dundee, because of problems with recruiting, the unit was moving away from relying so much on medical staff. The plan was to create two advanced nurse practitioner posts to cover daytime work such as clinics, and therefore, for the trainees to be free for other work. Regarding the Aberdeen situation, Eric asked Manny if he felt it was safe for the service to be covered by the sharing arrangement between neurology/surgery trainees? Manny replied that it was satisfactory for the moment, but that problems could arise at changeover. The majority of trainees did make an effort to learn and take part in the on call system. Eric said he would report to the Board that a clinical fellow post would be desirable in Aberdeen. 5

6 Action: EB 8. AOB Diane commented that there was a need to strengthen the AHP involvement so that these groups could feed in and contribute more effectively. The main current issue was likely to be workforce. There had been fairly random effects on a lot of disciplines and there was a need to identify these issues more clearly. An AHP subgroup was being set up, which would report at the next OMG meeting. Eric asked for any views from the SNC/Neurological Alliance meeting. Jennifer thought it had been an interesting day, though if the purpose of it had been to feed back to Government on the effects of policy on service, it had failed in that regard. She was disappointed that Ms Sturgeon had not attended and that her deputy Ms Robison had not been able to stay to take any questions. Eric reported that he and the MSN Chairman were meeting Ms Sturgeon on Thursday, which should allow time for discussion of the 18 RTT and other issues. He commented that as a group, to have that direct access was a real advantage. 6